A basket weaver at work with her baby at her side, in Tamil Nadu. The infant mortality rate is very high for working women, particularly those in the primary sector, a large proportion of whom are labourers.

A report on the 2013 deliberation of the Kolkata Group at its 10th workshop which focused on healthcare, the status of women and social justice in India.

A K Shiva Kumar (akshivakumar@gmail.com) is convener of the Kolkata Group workshops which are organised by Pratichi (India) Trust, the Harvard Global Equity Initiative and UNICEF India.

At the 10th annual Kolkata Group workshop in February this year, 40 policymakers, development practitioners, non-governmental organisation (NGO) representatives, scholars, activists, journalists, politicians and development experts convened to take stock of the state of women, health equity and social justice in India. The group focused on two major areas of concern. First is the abysmal state of healthcare in India driven by the lack of strong governmental policies, investments and direct operations, and the growing size and exploitive practices of commercial providers. And second is the limited progress in women’s rights, indeed sometimes retrogression, that is reflected by a host of inequities, insecurities and injustices.

The Kolkata Group is an annual forum that deliberates on ways of advancing social justice, human development and human security in India. The group examines available information, seeks positive solutions, and shares its recommendations with wide audiences – government, civil society, the media, and the public. The group believes that bringing together outstanding people from different walks of life to discuss “good practices” and “lessons learned” can blend values, knowledge and discourse as part of a process of public reasoning for social action. Every year the group discussions have a particular focus. Themes in the past have included equity, security and basic education, rights and resources, child rights and development, economic progress and social values, and eliminating injustices in India. The theme in 2013 was “Public Action and Its Future”. The main focus was on health and nutrition as well as the alarming status of women in Indian society.

Amartya Sen opened the workshop by underscoring that economic growth in India is good and necessary, because average incomes must be raised to achieve reasonable living standards and extensive income redistribution alone would not be sufficient for shared well-being. Growth generates private income, and even more importantly, it generates public resources which can be spent on the provision of a host of essential goods and services that contribute to decent living standards. Having noted this, Sen argued that it would be a mistake to “sit back” and rely on economic growth alone to transform the living conditions of the unprivileged. While India has much to learn from growth-mediated development elsewhere in the world, it must avoid unaimed opulence – an undependable, wasteful way of improving the living standards of the poor. Even today, after 20 years of rapid growth, India is still one of the poorest countries in the world, something that is often lost sight of, especially by those who enjoy world-class living standards thanks to the inequalities in the income distribution.

On several health indicators, India has fallen behind many of its neighbours. Overall in 1990, India had the best social indicators in south Asia, next to Sri Lanka. But now India ranks second-worst, ahead of only Pakistan. This is despite the fact that during the last 20 years, India has grown richer much faster than its neighbours. Take for instance Bangladesh. India’s per capita income was estimated to be 60% higher than Bangladesh in 1990. By 2010, India’s was 98% higher (about double). However, during the same period, Bangladesh overtook India in terms of a wide range of basic social indicators: life expectancy, child survival, fertility rates, immunisation rates, and even some (not all) schooling indicators such as estimated “mean years of schooling”. Bangladesh’s relatively rapid transformation of social indicators seems to relate closely to the much greater participation and agency of women in the social services as well as in private economic activities, compared with India.

Equally intriguing is that Nepal is also catching up rapidly with India, even overtaking India in some respects. Around 1990, Nepal was way behind India in terms of almost every development indicator. Today, social indicators for both countries are much the same (sometimes a little better in India still, sometimes the reverse), in spite of per capita income in India being about three times higher than in Nepal. Looking at their south Asian neighbours, the Indian poor are entitled to wonder what they have gained – at least so far – from the acceleration of economic growth.

Even though India is still managing to achieve comparatively high growth rates, despite its very insufficient public provision of basic services, this is undoubtedly a source of future concern, and may already be playing a part in India’s contemporary slowdown. High growth in east Asia has been led by, and reinforced by, rapid formation of human capabilities, and this is the shared experience of Japan, China, South Korea and other fast moving economies and societies in Asia. The contrast with India cannot be sharper. Apart from the very limited reach of good quality healthcare and basic education, even today 48% of the population do not even have toilets in their homes. India suffers a chronic power shortage as the breakdown of the grid in north India last year highlighted, but it is also worth bearing in mind that a third of the population in the “black out” area did not ever have any electricity connection anyway. But Sen said you would not think that power supply was a problem in India if you visited government offices where the air-conditioning is kept at a bone-chilling 16 degrees celsius in the summer. This was quite unlike government offices in other Asian countries, which keep the temperature around 23 degrees, which is comfortable enough. It is hard to detect any sign of power supply being a problem if one visits over-chilled offices, restaurants, or hotels, patronised by the comparatively rich, and it would be hard to guess that a third of the Indian population is without electricity altogether. Is it also not ironical – or worse – that political parties support, rather than object to, subsidising electricity for the “middle class” in the name of the aam aadmi? This goes along with support for other middle-class consumptions, such as diesel, cooking gas, and other ingredients of a lifestyle from which the poor are excluded.

Health Inequities

Discussions drew attention to the Asian experience, beginning with Japan in 1860 after the Meiji Restoration, South Korea, Taiwan, Hong Kong, Singapore, Thailand and China, where economic progress was driven by rapid human capabilities formation. We, in India, are trying to target a high growth rate without investing adequately in basic health, nutrition and education. In this connection, several participants pointed to the appalling state of India’s health system. Public healthcare has been relegated to low priority by the government, given that public spending on health in India is around 1.2% of its gross domestic product (GDP) – and has remained so for the past five years – whereas it is 2.7% of GDP in China.

The Kolkata Group reiterated that the most urgent need in healthcare in India today is for an affirmative approach that advances universal health coverage through reversing the financial neglect of public healthcare and the removal of debilitating illusions about what private healthcare and commercial insurance can achieve without firm and active public policies. Influential policymakers in India seem to be attracted by the idea that private healthcare, properly subsidised, or private health insurance, subsidised by the state, can meet the challenge. However, there are good analytical reasons why this is unlikely to happen because of informational asymmetry (the patient can be easily fooled by profit-seeking providers on what exactly is being provided) and because of the “public goods” character of healthcare thanks to the interdependences involved. There are also major decisional problems that lead to the gross neglect of the interests of women and children in family decisions. Nearly every country in the world which has achieved anything like universal health coverage has done it through the public assurance of primary healthcare (whether in Europe, Canada, or much of east Asia).

India’s leaders ought to recognise the necessity for the state to ensure comprehensive quality primary healthcare for all. Related to the main focus of the recommendations, the Kolkata Group urged the government to increase public spending on healthcare to achieve its well-considered pledge of devoting at least 3% of GDP to healthcare. It is particularly important to recognise that there are good reasons for demanding universal entitlements to primary healthcare for all. Effective regulations and ethical professionalism are also essential. The steady increase in public revenues generated by economic growth can and should be fruitfully committed to this extremely important cause.

Child Nutrition

Related to health is India’s worrisome record in reducing child malnutrition. Noting the unusually high levels of under-nutrition in India, the Kolkata Group argued for a firm recognition of the Right to Food in general and legislation to guarantee the entitlements to food for all. Recent experience (including Supreme Court orders on the right to food as well as the National Rural Employment Guarantee Act) shows the value of putting economic and social rights in relation to a legal framework. Legislation should recognise that food and nutritional security depends not just on food but on a set of related interventions that promote women’s health and nutrition, safe drinking water, proper sanitation and healthcare.

The Kolkata Group had earlier endorsed the proposal for creating durable legal entitlements that guarantee the right to food in India. A Right to Food Act covering justiciable food entitlements should be non-discriminatory and universal. Entitlements guaranteed by the Act should include foodgrains from the public distribution system (PDS), school meals, nutrition services for children below the age of six years, social security provision and allied programmes. Ensuring non-discriminatory access and universal entitlements requires special initiatives that focus on the discriminated, disadvantaged and vulnerable groups in society. Last but not least, design and implementation should include effective public participation, grievance redress provisions and independent oversight.

Women’s Rights

The Kolkata Group also drew attention to the limited progress in women’s rights that continues to be plagued by a host of inequities, insecurities and injustices. Discussions were grounded in the developments following the incident of gang rape on 16 December 2012. Nirbhaya’s statement, “I want to live”, provided a very strong emotional impetus to the protests by large numbers of women and men from different sections of society. The fact that many people went past without helping when Nirbhaya was lying there with her friend wounded reveals something awfully callous about us. Similarly, it is not to our glory that dalit women have been violated and raped again and again. And there has been relatively little noise or protest. Underlying causes for the neglect and abuse of women include patriarchy as well as deep cultural factors.

Increasing the enormity of punishment in cases involving crimes against women does not necessarily solve the issue of rising crime against women. Awarding the death penalty, for example, can serve the purpose of revenge but it does not help in social reform. Society needs to ensure that the police are serious about such crimes, there is a system that will punish those responsible for the crime, and that such matters are tried expeditiously in a court. Indian women experience much greater difficulties in getting help from the police, and consequently do not trust the police to work in a professional manner. Protocols should be adopted to protect female complainers and in moving the court swiftly enough to get a judgment quickly.

The Kolkata Group noted that the violations of women’s rights are related to the continuation of early child marriage, violence against women, discriminatory practices, the impunity and bias that permeate the functioning of the legal and police systems, malnutrition of women and children, increasing prevalence of sex selection at birth as well as inadequate women’s autonomy, health, education, and freedoms. The steps ahead must recognise the recommendations of the Justice J S Verma Committee report promoting women’s bodily integrity, dignity and sexual autonomy. Serious attention should be paid to health, education, nutrition as well as the lack of adequate recognition of women’s well-being and agency. The group also underscored the importance of public protests and the need to keep raising the demand for a police and legal system that protects the rights of women. Women’s needs have to be more centrally recognised as a political priority for their voices to be heard.

Narendra Modi of the RSS is an ambitious man who seems to want to become the prime minister of the country. His propaganda machine never speaks of the violence in 2002 in the state he ruled and rules, but it constantly plugs his hand in its development. I do not propose here to question the claims of development that he makes or which are made for him. Better qualified people have done that and have shown that these claims are based on sleight of hand or on outright lies. I shall only look at the meaning of this development business in Modi’s lexicon.

Modi’s own web site, at http://www.narendramodi.in/media-detail/?gid=11636 declares, “Development alone is the solutions [sic] to all problems: Shri Modi delivers inspiring address at SRCC!” Apparently the man said, “We are not pitching our tent on a single pillar. Our development model is based on 3 aspects — development of agriculture, industry and services sector. We want all 3 sectors to grow where each supports the other so that state economy is never in trouble.” This is typical of his populist demagoguery. A seemingly rational enumeration slips magically sideways and becomes a conclusion.

Here is a better one: “In 2001-02 when I became CM, 23 lakh bales of cotton was produced, today it stands at 1 crore 23 lakh bales. Our next step should be value addition. So we are working on that. We got a new Textile Policy. We have a 5F formula — from Farm to Fibre to Fabric to Fashion to Foreign. Till we do not take integrated approach then nothing will happen.” The reasoning is as devious as the grammar is slippery. The man jumps about like a grasshopper, dispensing wisdom probably obtained from his advertising consultants and speech writers: “We have to adopt ‘Zero Defect Mantra’ and other is packaging. We need to study consumer psyche and then work on manufacturing sector.” Such specimens as Modi cannot be pinned down. It is an established tactic of the Hindutva Brigade to change tack constantly, particularly when in trouble.

It was not an accident that economists, the very people who measured development in arid figures, began in the 1980s to look at human beings not as statistics but as the central concern of development. “Human development” has been so described by two of the people responsible for the new approach:

“People often value achievements that do not show up at all, or not immediately, in income or growth figures: greater access to knowledge, better nutrition and health services, more secure livelihoods, security against crime and physical violence, satisfying leisure hours, political and cultural freedoms and sense of participation in community activities. The objective of development is to create an enabling environment for people to enjoy long, healthy and creative lives.” Mahbub ul Haq, quoted in http://hdr.undp.org/en/humandev/.

“Human development, as an approach, is concerned with what I take to be the basic development idea: namely, advancing the richness of human life, rather than the richness of the economy in which human beings live, which is only a part of it.” Amartya Sen, same source.

Unlike the old idea of development, from which only the capitalists and the affluent benefit, human development explicitly is concerned with what all social classes get, including the poor and those who are customarily forgotten, the religious minorities and the tribals. On the other hand Modi, the glorious Hercules of Development, starves the Muslims of Gujarat and denies them housing, health care and education. Hardly surprising, because he belongs to the tribe which wants free and secular India to become the monarchical Hindu Rashtra which they believe to have existed in an earlier age.

Mukul Dube is a writer, photographer and editor who lives in Delhi. He can be reached at uthappam@gmail.com

KOLKATA, 18 FEB: The country needs a “completely fresh approach” to health care Nobel laureate Amartya Sen said today, as an over-reliance on the private sector and lack of commitment from the state means it has gone “really, badly wrong”.

At a press conference this evening at the Taj Bengal hotel in Alipore to round off two days of discussions as part of his Kolkata Group workshop ~ an annual brainstorming session on pressing social issues for policymakers and activists ~ Mr Sen said the state needs to express a commitment to universal health care for all.

This could come in the form of legislation setting out a right to health, along the lines of the Right to Education Act, he said, although this wouldn’t in itself solve everything. “It alone will not cure the problem, and it will not become a perfect right to health just through the declaration. A number of ancillary things have to happen, including greater allocation of public funds to health care, which are woefully poor now.”

While other countries are moving to spend more resources on healt care, India is “totally stationary,” he said. “India is an outlier. I mean very little government commitment on expenditure and delivery.”

He said there is also “a very nasty and costly misunderstanding” that private health care can step in to bridge any health services gaps. There are also problems with relying on private medical insurance as a model, he said, pointing to difficulties that some people have been getting coverage if they have pre-existing conditions. “The reliance on private health care and the illusion that that can solve the problem is a major issue,” he said. “No country has been able to have a transition from bad health to good health on the basis of private healthcare.”

There are many good doctors working in the country, Mr Sen said. But he also expressed concern over “lack of professionalism in the medical community,” a problem he says needs to be tackled.

Mr Sen and his colleagues at the Kolkata Group also issued a declaration based on the debates they have had over the last couple of days. It not only called attention to the “abysmal state of health care” in the country, but also “the slow and very limited progress in women’s rights that includes a host of inequities, insecurities, and injustices.”The group in its declaration called upon the government to “recognise the recommendations of the Justice J S Verma Committee Report promoting women’s bodily integrity, dignity, and sexual autonomy.”

Amid the nationwide debate over giving rapists the death penalty, Nobel prize winning economist Amartya Sen is not in favour of capital punishment, saying it does not serve as a “deterrent” and “preventive function”.Sen at the same time said today he was not against “severe punishment” in critical cases.

In an oblique reference to the Delhi gangrape case, he said, “I am not for letting them (culprits) go.”

“Death sentences do not serve as a deterrent and its efficacy as a capital punishment is doubted based on empirical grounds and is not a preventive function,” Sen said addressing a seminar on ‘Realisation of Justice’ organised by the Calcutta High Court here.

Sen said, in India, awarding of death sentences was much lower than China where it was the highest in the world.

“In India, death sentences are awarded, but not executed except for recently in the case of Mumbai attacks,” he said.

“I am not against severe punishment in case of critical cases,” he added.

In the course of his lecture, he also referred to the Sanskrit play Mrichhakatika (The Little Clay Cart) where Charu Datta set the criminals free instead of punishing them.

“The play showed that tit-for-tat justice does not bring well to the world in the realms of prosperity, happiness and security for all,” Sen said.

TOPICS

Eminent economist and Nobel Prize winner Amartya Sen has said the Union government’s cash transfer scheme can be a useful system to supplement other ways of making India a less unequal society, “but it is not a magic bullet, and its pros and cons have to be assessed and scrutinized with an open mind.”

In an interview to The Hindu, Dr. Sen said the modality of cash transfer is not the only issue “but also how much, and for whom, and also, instead of what?”

He sounded a note of caution in cash transfer of food subsidies, saying direct access to food often helps reaching nutrition to children and girls. But when the subsidy is given as cash directly it may benefit adults and boys more due to biased social priorities in Indian society.

Dr. Sen said the transition delays in cash transfer could cause extreme hardship to people, many of whom lead a hand-to-mouth existence.